Radiologists Should Worry About Medical Device Tax, Too

Published on the Jan. 10, 2013, DiagnosticImaging.com website

By Whitney L.J. Howell

On January 1, the long-debated and much-opposed medical device tax went into effect. To date, medical device manufacturers have clearly stated their opposition, but industry leaders portend practicing radiologists also have reason to be concerned.

Barely a week old, this measure levies a 2.3 percent tax on all medical devices. The law calls for manufacturers to pay for the tax added to the sale price of the device, but many worry the cost will not only trickle down to providers, but will also, ultimately, stymy the progression of patient care by hindering research and development efforts.

“As radiologists, most of us chose the specialty because it’s a field that incentivizes technological innovation that can make enormous differences in patient care,” said Geraldine McGinty, MD, chair of the American College of Radiology (ACR) Economics Commission. “Payment or health care policies that would, in any way, negatively impact innovation are things that make us feel uncomfortable.”

The device tax will inevitably impact practitioners’ bottom lines, she said. The actual dollar amount is yet unknown, but manufacturers will be forced to pass some of the tax increase on to their customers. The price hike will likely be an unwelcome addition to existing imaging reimbursement cuts and the difficulties radiologists already face with collecting payments from patients. Equipment purchasing decisions could become more complicated or could be postponed, she said.

In addition to individual monetary concerns, radiologists should also worry about what the medical device tax could mean for their ability to provide the most up-to-date patient care. According to the Medical Imaging and Technological Alliance (MITA), this initiative is a job-killer because it makes outsourcing jobs overseas more attractive. But research and development efforts will also be a casualty, said MITA Executive Director Gail Rodriguez.

According to a recent MITA survey, 29 percent of manufacturers anticipate slicing into their research and development budgets as a way to cover the anticipated $287 million associated with the device tax. This change could leave providers without new technological innovations for treating patients, MITA said.

To read the remainder of the story at its original location: http://www.diagnosticimaging.com/practice-management/content/article/113619/2122393

Proposed Cuts Lead to Radiology Practice Self-Analysis

Published on the Nov. 14, 2012, DiagnosticImaging.com website

By Whitney L.J. Howell

When CMS released its 2013 proposed Medicare payment cuts this month, no one in radiology was particularly surprised. Industry experts knew radiology settings and providers faced slashed reimbursement rates, and it’s now time for practices to assess just how affected they might be.

In the fee schedule, set for Jan. 1, 2013, implementation, CMS retained its proposed multiple procedure payment reduction (MPPR) of 25 percent to the professional component (PC) for CT, MRI, and ultrasound imaging conducted by one or more providers in the same practice on the same patient, during the same session, on the same day. The Medicare proposed cuts will also decrease overall payments to radiation therapy centers by 9 percent and reduce payments to radiation oncology providers by 7 percent.

Overall reaction, said Maurine S. Dennis, senior director of economics and health policy at the American College of Radiology, is that these proposed reductions are both arbitrary and complicated. The MPPR cut is creating significant angst, she said.

“It’s a cut — a cut to the professional component, so it’s real money out of our providers’ pockets,” she said. “The proposal deals a lot with subspecialists, and it’s complex. It’s going to take time to figure out how everything will shake out.”

The looming 25 percent MPPR cut isn’t the only problem, however, said Mike Mabry, executive director of the Radiology Business Management Association. CMS has also yet to publish any information or guidance about the new coding modifier it plans to implement for same-day, same-provider services. Currently, your coders use the -59 modifier to identify procedures done on the same day that are distinct from all others performed.

In addition, the agency has not released a definition for what it considers to be same-session, leaving practices to determine for themselves how best to process this type of claim. The best course of action, Mabry said, is for practices to conduct a self-assessment of how at-risk they are for MPPR PC payment cuts.

Practices that provide a higher level of tertiary care or other advanced diagnostic imaging services should conduct the most involved analyses of their same-day, same-session services. These settings, he said, will be the most vulnerable to the MPPR PC reduction and will feel the greatest impact on their bottom line.

To read the remainder of the story at its original location: http://www.diagnosticimaging.com/practice-management/content/article/113619/2114454

Influencing policy – Changing the way things are done

Published in the Fall 2012 Carolina Public Health Magazine

By Whitney L.J. Howell

UNC Gillings School of Global Public Health faculty members and alumni lead state, national and international programs, making an impact upon health outcomes including disease reduction, food choice improvement and enhancement of services for domestic violence victims.

Leah Devlin, DDS, MPH, Gillings Professor of the Practice in health policy and management, secures economic safety and health for North Carolina’s children through her appointment to the policy group Action for Children. Currently, she tackles smoking and obesity prevention.

As North Carolina’s state health director and public health division director from 2001 to 2009, Devlin accomplished a great deal, including policy changes for public schools. Under her leadership, the health department developed comprehensive school health programs, placed nurses in schools, mandated regular physical activity and required nutritious lunches. During her tenure, mental health and injury prevention services also were introduced.

“You cannot separate health and education from outcomes,” Devlin says. “Children must be healthy to learn. If a person doesn’t graduate from high school, he or she is less able to earn a decent wage and therefore less able to live in healthy environments or purchase healthy foods. The impact of poverty, lack of education and housing issues shapes health policy.”

Although 2009 alumna Kristal Chichlowska, PhD, MPH, concentrates on social indicators driving California’s health disparities, her work is important to North Carolina. As director of the California Tribal Epidemiology Center at the California Rural Indian Health Board (www.crihb.org), she serves 109 American Indian tribes routinely
underrepresented in epidemiologic data.

Physicians often misclassify American Indian and Alaska Native patients’ ethnicities, masking the groups’ childhood and
chronic disease burdens. Without accurate data, health programs cannot secure funding to meet community needs.

“For instance, we found California’s American Indians were misclassified in state health databases up to 60 percent for
some health outcomes,” Chichlowska says. “Now, we advocate for oversampling, pushing the state capital and federal agencies for data improvement.”

Since 2010, the epidemiology center has surveyed these communities about diseases and published data online, she says. This information bolsters CRIHB’s outreach effort to enhance policies.

Sandra Martin, PhD, maternal and child health professor, evaluates the performance of policies and strategies. As a Governor’s Crime Commission member, she and her co-members analyze domestic violence and sexual assault programs and helped develop a standardized, statewide reporting system.

The question, she says, is whether these programs can use the system to provide care.

“We’re surveying all programs about their capacity for using the new system, and we’ll offer necessary training,” she says. “We’re also looking at how well programs address substance abuse. It’s a sensitive topic people often ignore because they’re uncomfortable talking about it.”

Martin’s research revealed four components vital to understanding the efficacy of domestic violence and sexual assault services – the victim’s satisfaction with the services, victim’s progress toward goals, changes to violence victims experienced and changes in victims’ knowledge about services.

Martin also has studied child maltreatment in military families. She found abuse occurs more frequently when one parent –
frequently the father – is deployed. Congress used these findings to increase family support services during deployments.

The School’s dean, Barbara K. Rimer, DrPH, is chair of the President’s Cancer Panel, the group charged with monitoring the nation’s cancer effort.

The panel has organized a series of four workshops to develop strategies to accelerate cancer prevention by increasing the proportion of age-eligible individuals who are vaccinated against human papillomavirus (HPV) infections. Noel Brewer, PhD, associate professor of health behavior, co-chaired the second workshop, titled “Achieving widespread vaccine uptake.”

Increasing vaccine access is critical to eliminating avoidable disease, Rimer says.

“A vaccine to prevent cancer is the Holy Grail of cancer control. Yet, only about 30 percent of girls and less than 2 percent of boys have been vaccinated,” Rimer says. “If we identify promising strategies to increase HPV vaccine use, then, indirectly at least, we’d contribute to preventing cancers. That’s why I’m doing this.”

While the advisory panel cannot mandate action, Rimer wants health organizations to help implement proposed policies and recommendations. Cervical Cancer Free NC (www.ccfnc.org), based at the School and led by Brewer, is one such effort, aiming to reduce or eliminate cervical cancer in North Carolina by advocating for vaccination, screening and treatment.

HPV causes more than 560,000 new, worldwide cases of cervical, oropharyngeal and other cancers annually. For Brenda Edwards, PhD, who received her biostatistics degree at the School in 1975, the goal is reducing all cancers – her objective
at the National Cancer Institute (NCI) since the 1990s. Now, she is senior adviser to NCI’s Surveillance, Epidemiology and End Results (SEER) database – a registry from 15 major cities, totaling roughly 28 percent of the U.S. population. The data include patient demographics, primary tumor site and morphology, stage-at-diagnosis, first-treatment course and follow-up.

“These data look beyond clinical trial results for a better picture of how to use and apply outcomes to impact total populations,” Edwards says. “Studies and modeling groups can analyze SEER data to see who gets cancer, mortality rates, data changes over time, risk factors and how to minimize risk.”

The Food and Drug Administration uses the statistics to determine orphan drug status (an orphan drug is developed specifically to treat a rare medical condition). The statistics also help NCI extrapolate the number of new diagnoses annually. Such estimates inform Medicare and Medicaid policy decisions, Edwards says.

For many patients, health care is obtained at rural, critical-access hospitals (CAHs), which often don’t monitor their financial status. To help these vital facilities track expenditures, George Pink, PhD, Humana Distinguished Professor of Health Policy and Management, and Mark Holmes, PhD, health policy and management assistant professor, developed the Critical Access Hospital Financial Indicators Report, based on data from 300 CAHs.

Using 21 financial ratios, the report identifies hospital financial strengths and weaknesses. Thus, facility and state program
administrators can pinpoint institutions that could benefit from grant funding or consultant guidance, Pink says.

“The hope is that these data will help hospital managers think strategically and strengthen their system to adapt and survive when federal reimbursement rules change,” Holmes says. “It’s something they might not have been able to do prior to getting these reports.”

In 2009, President Obama appointed David B. Richardson, PhD, associate professor of epidemiology at the School, to the White House Advisory Board on Radiation and Worker Health.

Two years later, Japanese citizen groups and public health researchers called upon Richardson’s expertise in radiation after a national disaster. When a horrific earthquake and tsunami damaged a nuclear energy facility, Richardson advised about the development of policies that would keep the Japanese people safe and about long-term strategies to understand health effects of the disaster.

Richardson’s research investigates occupational and environmental causes of disease, with a particular focus on ionizing
radiation. He has served in various capacities at UNC since 1996 when he began as a postdoctoral researcher.

He has led a number of studies of workers at U.S. Department of Energy facilities focused on occupational health and radiation exposures. Previously, he worked at the World Health Organization’s International Agency for Research on Cancer in Lyon, France, and at the Radiation Effects Research Foundation in Hiroshima, Japan.

Barry Popkin, PhD, W.R. Kenan Jr. Distinguished Professor of nutrition, improves global food choices by helping countries establish proper nutrition labeling guidelines. Currently, only The Netherlands has national labeling policies. This dearth of guidance troubled Popkin.

“I had to get involved when I saw the food industry – global and stateside – creating labeling systems to allow enormous amounts of sugary, salty and fatty foods to be labeled as healthy,” Popkin says. “I knew it was essential for a scientist to create an appropriate, science-based system.”

Based on World Health Organization and U.S. standards, these labeling policies reduce added sugars and sodium, lower trans and saturated fats, and increase whole grains, legumes, fruits and vegetables. Seven additional countries are considering a national labeling policy, Popkin says, to control obesity, diabetes and other diet-related ailments.

To read the article at its original location: http://www.sph.unc.edu/images/stories/news/cph_2012_fall/documents/influencing_policy.pdf

Connecticut’s Dense Breast Legislation Three Years Later

Published on the Oct. 23, 2012, Diagnostic Imaging website

By Whitney L.J. Howell

Connecticut launched its law mandating providers alert women if they have dense breasts and offer supplemental ultrasound screenings three years ago. The road has been rocky — radiologists initially resisted it, the density legislation confused many patients, and few women seemed interested in the secondary scans. But new research shows the law has resulted in more cancers found.

Much discussion surrounded Connecticut’s dense breast tissue law when it passed in 2009, requiring referring physicians to inform women with dense breast tissue that they could benefit from supplemental ultrasound screening. A recent study revealed the law had a slow, but effective, start.

In research published in the October issue of Radiology, investigators from Yale University determined less than 20 percent of women with dense breast tissue opted to have an ultrasound screening after receiving abnormal mammogram results. The retrospective review analyzed the ultrasound results for nearly 1,000 women who underwent the procedure.

Although fewer women than anticipated opted for ultrasound screenings after the law took effect, lead study author Regina Hooley, MD, assistant professor of diagnostic radiology, said giving patients the option of supplemental ultrasound screening after a mammogram was useful. Based on data pulled from the legislation’s first year, her team found additional 3.2 cancers per 1,000 women were discovered using ultrasound.

“These findings are right in the ballpark for the amount of cancers we identify with mammogram,” Hooley said. “Although mammography is the only test with data to show it reduces breast cancer-related mortality, it’s clear, with this study, that ultrasound provides an acceptable cancer detection rate at an acceptable cost.”

In January, Texas enacted its own version of the law, known as Henda’s Law. And, the American College of Radiology anticipated 13 additional states introducing some type of similar legislation during 2012.

According to the study’s cost analysis, each cancer identified via ultrasound cost approximately $60,000. That figure equals roughly $200 per patient, Hooley said. It’s also important to note that Connecticut insurance companies are required, under law, to cover these supplemental ultrasound screenings.

Connecticut radiologist Jean Weigert, MD, who serves as treasurer for the Radiological Society of Connecticut, also tracked supplemental ultrasound screenings in her practice. Her results, she said, are exactly the same as Hooley’s.

To read the remainder of the story at its original location: http://www.diagnosticimaging.com/womens-imaging/content/article/113619/2110186

Former NASA historian says agency’s future lies with unmanned projects

Published in the Sept. 17, 2012 Raleigh News & Observer and Charlotte Observer

By Whitney L.J. Howell

We asked Alex Roland, professor emeritus of history at Duke University, to put the current Mars Curiosity mission in a perspective. Roland is a former NASA historian.

Q: What are the benefits of unmanned space exploration, such as the Mars Curiosity?

One question has driven all current space exploration: Was there ever, or is there now, life on Mars? It’s likely if there were, it’s disappeared, but we might find evidence. That would have enormous implications for the space program and for the human race and condition. It would suggest we’re not unique in the universe.

Such a discovery would increase NASA’s emphasis on getting the country to agree to a manned Mars mission. NASA sees itself as having had a golden age with the Apollo program. Ever since, it has tried to find something else to capture public imagination to justify a large increase in our space activity spending. Curiosity plays an interesting role because if it finds evidence, NASA can increase its manned mission push. But Curiosity is such a capable exploration vehicle, and it’s so much cheaper and less dangerous than a manned mission, that many of us believe we should invest in more Curiosities.

Q: What’s the advantage of unmanned missions?

Whenever you send people to space, the expedition’s purpose changes. To explore Mars, we can send up as many remotely controlled vehicles as necessary. They’re uniquely designed for exploration. A manned mission must get people there and back safely. That trumps all else, and it limits exploration. Humans can only do safe exploration. Their exploration time is limited because they must return to Earth soon. It also limits the equipment sent up because astronauts need a lot of life support. For exploration, we’re better off sending custom-designed, remotely controlled, automated spacecraft. There’s nothing humans can do on Mars that a machine can’t. Sending people increases risk and diverts the mission’s goal.

Q: Are there potential technological gains from the Curiosity mission?

Investing in science and technology, especially research and development,

This panorama image of Curiosity’s lower front and underbelly combines nine images taken by the rover’s Mars Hand Lens Imager on Sept. 9. Fine-grain Martian dust can be seen adhering to the wheels, which are about 16 inches wide and 20 inches in diameter. The bottom of the rover is about 26 inches above the ground. On the horizon at the right is a portion of Mount Sharp, with dark dunes at its base. The imaging by MAHLI was part of a week-long set of activities for characterizing the movement of the arm in Mars conditions.

always produces spinoff. Second-order consequences and unanticipated technological applications can be useful in other fields. But that comes from any R&D. NASA’s spinoff record isn’t great. It has claimed the dollars it has invested produced more spinoff technology, but that mostly isn’t true. There’s nothing specific NASA does that makes R&D any more productive.

Q: Could this Mars mission be seen as a relaunch of space exploration?

Whenever I hear of manned Mars missions, my first question is, “Why?” What will we do? Will it be like Apollo where we send humans there and bring them home safely, and that’s the end?

NASA maintains manned Mars missions will be part of a permanent space colonization program. That begs the question of why colonize Mars? Sending humans there to take pictures, scoop soil, and return safely will cost hundreds of billions of dollars. An initial colonization mission would cost probably around $1 trillion just to get started.

So, it’s reasonable to ask the purpose and benefit of having people on Mars. A good comparison is the International Space Station. We paid more than $100 billion to put it up there and never found a good use for it. Within a decade, we’ll likely abandon it, let it decay in orbit, and burn up in the atmosphere. If we can’t find a good use for the space station that’s comparatively close and safe – even though we’ve lost two space shuttles and crews going there and back – how do we think we’ll find a good use for humans on Mars?

Q: What continues to drive NASA toward manned exploration? Are we still searching for our place or role in the universe?

That’s exactly it. When NASA sent the first crew to the space station, it stressed this reflected both the agency’s and our country’s place in history. It emphasized this was the beginning of permanent human space habitation. It believed from then on humans would be in space and people would look back and remember America, NASA, and the space program.

But there’s no commitment to fund the space station very far into the future. It’s too expensive to maintain, and it’s not doing anything useful.

NASA will argue strenuously to maintain a space presence. We all love NASA. We love what they do and think they’re good and capable. But the public has a right to ask what we’re getting for our investments, especially when budgets are stressed.

Q: In the last decade, space exploration has shifted from government-funded enterprise to the private sector. Will this continue?

I’ve long been skeptical that private companies without government subsidy can make money flying in space. There isn’t that much money to be made. It’s a big business, but it’s not what most private venture firms are motivated by. Often, it’s idealistic, very wealthy people with lots of money to invest.

They grew up in the space age. They want the same permanent space presence NASA wants, and they’re going to help make it happen. I think we’re seeing evidence they can build launch vehicles and operate them more cheaply than NASA. But do they have a business model for sustainable programs and making money?

None will reveal how much they’ve spent, and without long-term, sustainable business models, venture capital isn’t attracted. It’s unclear how many companies will make money.

NASA’s trying to help them because if companies assume routine activities, like launching satellites or resupplying the space station, then NASA can divert funding to futuristic enterprise, including manned Mars missions. Perhaps NASA has enough business to keep them going for a while, but not enough for long-term profit. One strange peculiarity of modern technology is the satellites we launch now are so big and powerful we don’t need as many of them as we used to.

Q: What can NASA do to reignite or reinvent itself?

What many at NASA only say privately is the public often doesn’t appreciate NASA’s unmanned spacecraft magnificence. It has transformed how we understand the universe and presented research possibilities, but NASA’s believed its public and congressional support and budget depend on manned space exploration.

NASA has believed people don’t care about space science, communication and weather satellites. But these technologies give us today’s world. Manned space flight has been little more than circus or stunt. Astronauts go up, float around, and return without accomplishing much.

Curiosity exemplifies how exciting unmanned space activity is, and how interested the public can be if NASA educates them.

To read the Q&A at its original Raleigh News & Observer location: http://www.newsobserver.com/2012/09/16/2346665/what-will-follow-curiosity.html#dsq-content

To read the Q&A at its original Charlotte Observer location: http://www.charlotteobserver.com/2012/09/16/3534401/what-will-follow-curiosity.html#storylink=misearch

Meaningful Use Stage 2 Rule Offers Radiologists Some Clarity

Published on the Sept. 6, 2012 DiagnosticImaging.com website

By Whitney L.J. Howell

The final rule for Stage 2 of the Meaningful Use (MU) program, released last month, clarifies a few sticking points for the radiology industry, but some questions remain, say industry experts who are still digging through the specifics of the rule.

Still considered to be a move toward standards-based health information exchanges, the final rules for Stage 2 — released by CMS and the Office of the National Coordinator (ONC) set to take effect in 2014 —provide some additional clarity for how radiologists and hospitals should approach MU. But they’re little changed from the proposed versions. The similarities, some said, are surprising.

“It’s interesting that CMS’ final rule resembled the proposed rule as much as it did,” said Michael Peters, legislative and regulatory affairs director for the American College of Radiology (ACR), noting the short time between the publication of the proposed and final rules. “This was probably the result of an extremely quick rule-making that spent less time addressing stakeholders’ concerns.”

Individual providers and practices shouldn’t change their daily workflow and activities just yet, Peters said. The final rule, its requirements, and menu items, have not yet been completely analyzed.

However, it’s clear so far that the final rules offered additional guidance in three main areas: imaging accessibility, computerized physician order entry (CPOE), and hardship exemptions for meeting MU requirements. These areas have also been points of concern for the ACR.

According to Keith Dreyer, DO, chair of the ACR IT and Informatics Committee-Government Relations Subcommittee and radiology vice chair at Massachusetts General Hospital, the final rule guidance should make MU compliance easier for practicing radiologists. It combines certification criteria for eligible hospitals and eligible providers (EPs) in hospital settings with certified electronic health record (EHR) technology. The rule also impacts clinical quality measures.

“The clinical quality measures are better aligned with other quality incentive programs, making the overall process simple to achieve,” he said.

Fortunately, the final rule doesn’t require providers to store imaging results in an EHR with the ONC abandoning its proposal that images be available for download and transfer to third parties. Instead, they can offer a link to study results. In addition, CMS is only requiring 10 percent of images to be accessible this way instead of the 40 percent suggested in the proposed rule.

This change is a double-edge sword, Dreyer said. While it does relieve some of the pressure EPs felt regarding image accessibility, it also affects patients.

“It was disappointing to see the removal of the portion of the proposed MU objective requiring the ability for patients to view, download, and transmit their medical image data,” he said. “This was a common request of patients.”

To read the remainder of the article at its original location: http://www.diagnosticimaging.com/meaningful-use/content/article/113619/2101122

Public Service A Lifestyle for Knoxville Mayor Rogero

Published in the Summer 2012 Furman University Alumni Magazine

By Whitney L.J Howell

TAKE A LOOK around Furman’s campus and it’s clear there’s no “typical Furman student.” The student body is a mish-mash of ages, interests, ethnicities, accomplishments and goals.

But even among such a diversified group, Madeline Rogero was unique as a senior in 1979.

“I was a bit of an older student. I had one child already, and one was on the way,” she says. “My second child was just about
three weeks old when I graduated.”

That wasn’t the only thing that made Rogero stand out. She had transferred to Furman after a year at Temple University and two years as a political science major at Ohio State. Before her senior year, however, she felt called to help California’s farm aides — which led to a four-year hiatus from higher education, during which she worked with Cesar Chavez to help farm workers improve their living and working conditions.

Today, as mayor of Knoxville — the first woman to serve as mayor of any of Tennessee’s four largest cities (including Memphis, Nashville and Chattanooga) — Rogero says those kinds of experiences shaped her view not only of public service, but of what it means to be a contributing member of a community. She jumped head-first into improving Knoxville as soon as she moved there more than 30 years ago.

“I got my start in politics as a county commissioner. I cared about neighborhood issues,” she says. “I ran for mayor because I wanted to continue the work that I had been doing — dealing with blighted properties, strengthening our communities, and actively supporting sustainability issues.”

During the past three decades Rogero has served on numerous boards, including the Knoxville Transportation Authority, Partnership for Neighborhood Improvement, and the Mental Health Association of Knox County. Her efforts have earned her many accolades, including the 2003 Knoxvillian of the Year award.

Rogero has a long history of working to revitalize areas that have fallen into disrepair. After losing a close mayoral race in 2003 to Bill Haslam — now the state’s governor — Rogero joined his administration as community development director. The Office of Neighborhoods, launched under her leadership, was instrumental in completing a $25.6 million program that helped secure tax credits, grants and bonds for businesses in economically depressed parts of the city.

Rogero and her staff also spent countless hours on commercial redevelopment, historic preservation, property redemption, and services that enhanced the community’s economy. She spearheaded a five-county collaboration that garnered a $4.3 million grant to support sustainable community planning.

Even before taking the job with the city, though, Rogero pushed to improve her community. Among other responsibilities, she consulted with Capital One Financial Corporation’s community affairs office and was executive director of Knoxville’s Promise, an organization devoted to giving youths the resources they need to become successful adults.

As mayor, Rogero is focused on redeveloping Knoxville’s south waterfront and working with a local foundation to support 10 city parks, as well as hiking and biking trails.

Although she spent only a year at Furman, she credits her time there with helping her learn to translate her real-world, outside-the-box experiences into effective civic endeavors. She points to classes with professors Jim Guth and Don Aiesi as forums where she came to understand the value of her work with Chavez.

“I remember they would often call on me during political science and constitutional law discussions because I had a lot of real and practical experience to bring to those conversations,” she said. “They knew I had a different point of view.”

From a young age, Rogero says, she felt she would become involved in causes greater than herself.

“The nuns and priests [in her Catholic schools] challenged us to be involved,” she says. “A lot of different things were happening in the ’60s — the civil rights movement, the Vietnam War. That education opened my mind beyond my personal experiences and really
instilled in me a sense of working for the world to be more equitable, inclusive and diverse.”

Rogero also learned firsthand the importance of helping others during her childhood in Florida. At any given time, foster children or other family members lived in her house. Seeing her parents open their lives to those in need taught her to reach out to others whenever she could.

That time with family also nurtured Rogero’s love of nature. Her father, she says, loved to hunt and fish, and they spent a great deal of time at the beach or on the river.

Her affinity for the outdoors has never faded. Rogero and her husband, Gene Monaco, often bike around Knoxville’s greenways or use their flatwater kayaks to paddle down the Tennessee River. Her greatest outdoor adventure, however, is being a beekeeper.

“As a family, we suit up in the gear with the veil and the gloves, and we share the honey the bees make with friends and family,” says Rogero, a mother and grandmother of two and stepmother of three. “It’s a really amazing thing to get into when you realize that
one-third of the things we eat depend on honeybees for pollination. It’s really helped me to learn about and appreciate the ecosystem we live in.”

To read the article online at its original location (p. 33): http://www2.furman.edu/sites/fumag/Documents/FM12%20SUMMER%20low%20res%20spreads.pdf

CMS Releases Stage 2 Rule for Meaningful Use

Published in the April 2012 AAMC Reporter

By Whitney L.J. Howell

In late February, the Centers for Medicare and Medicaid Services (CMS) and the Office of the National Coordinator for Health Information Technology (ONC) released the proposed rules for Stage 2 of meaningful use and corresponding certification requirements. The rules introduce new measurements that doctors and hospitals will be required to meet to receive incentive payments for implementing electronic health records (EHRs).

The Stage 2 meaningful use rule is part of the Health Information Technology for Economic and Clinical Health (HITECH) Act, which was included in the 2009 American Recovery and Reinvestment Act. Under HITECH, hospitals and providers can receive Medicare and Medicaid incentive payments for adopting certified EHRs, using health IT in “meaningful” ways, and reporting clinical quality measures. CMS began making payments under the Stage 1 rule last year. With the law, Medicare hospitals and physicians who do not use health IT “meaningfully” will be penalized beginning in 2015. CMS has proposed criteria to determine which providers would be subject to this penalty. In most cases CMS plans to use a 2013 reporting period to identify proactively which providers are subject to a penalty, said Lori Mihalich-Levin, J.D., AAMC director of hospital and GME payment policies for health care affairs.

Industry leaders are still dissecting the details of the Stage 2 rule, but several key points already have emerged that will affect how providers approach meaningful use.

“CMS is obviously moving toward improved interoperability and information exchange,” Mihalich-Levin said. “However, there are some serious flaws with some of the proposed measures.”

The AAMC plans to submit its concerns to CMS and ONC by the May 7 deadline.

The biggest red flags in the new rule, Mihalich-Levin said, are proposals that require actions by third parties—in this case a patient—for the hospital or physician to meet the requirements. For example, hospitals and physicians must provide patients with online access to their health information. But in order to receive credit for meaningful use, at least 10 percent of patients must log on and actually view their records. An additional measure calls for at least 10 percent of patients to send their physician a secure, online message about their health care.

The problem, she said, is that there are no incentives for patients to comply, and providers cannot control whether patients feel comfortable with electronic communication, or have access to it.

“Hospitals can’t meet that requirement by implementing technology,” said Rod Piechowski, senior director of health information services at the Healthcare Information and Management Systems Society (HIMSS). “They must engage the patients on a different level, get them to take action, and recognize the value of the data. It’s a little bit out of their direct control.”

The proposed rule also increases the reporting requirements for many existing measures. For example, while Stage 1 called for 30 percent of medications to be ordered through computerized provider order entry, Stage 2 bumps the requirement to 60 percent of medications, and includes laboratory and radiology orders.

“This could be something that’s a minor change, but it will still require extra work to make sure we get the right groundwork in place,” said Tom Smith, chief information officer for Chicago’s NorthShore University HealthSystem. “It’s certainly a good idea to move away from writing down prescriptions on paper—ordering 100 percent of medications through e-prescribing would be great.”

Physicians and other clinicians who are eligible for the meaningful use incentives through Medicare also could benefit from the rule’s group reporting proposals. Rather than collecting quality measure data from each physician individually, beginning in 2014, CMS will allow doctors in group practices to report as a single unit.

“When you have a practice of hundreds or thousands of physicians, it’s logical to identify performance on clinical metrics as a group,” said Mary Patton Wheatley, AAMC manager of physician quality and payment policies. “Instead of a faculty practice trying to report measures for a variety of specialists and subspecialists (many of whom do not have relevant measures that can be reported through an EHR), the group reporting option allows the practice to focus on a single set of measures that makes sense for the practice as a whole and improves quality for the patient.”

Under the quality reporting requirement, beginning in 2014, hospitals would be able to choose which measures they report. While the element of choice is appealing, there are concerns about how this will ultimately impact the flow of measures used in other programs, including value-based purchasing.

It’s important to remember that any of these proposed measures could change in the final rule, which is expected this summer, Mihalich-Levin said. Until then, she recommended that institutions familiarize themselves with the various proposals. She added that after receiving feedback on the proposed Stage 1 requirements, CMS addressed many of the AAMC’s concerns in the final Stage 1 regulations. Over the next few months, the AAMC will review the proposed Stage 2 rules and encourage member institutions to provide feedback.

Smith agreed the proposed rule offers several benefits to teaching hospitals, but he cautioned that many of the meaningful use measures will require additional work from hospitals and physicians. Achieving certification or compliance, he said, will take time and resource investments to produce positive results.

According to Piechowski, hospitals that are just getting started on health IT will benefit from what others have learned.

“Hospitals should pay attention to what others have done, stay connected, get involved, and get ahead of the curve,” Piechowski said. “That is the best thing they can do. The people who are just getting in now are in an advantageous situation.”

Despite the challenges, health IT adoption is on the upswing. According to CMS, 35 percent of hospitals were using EHRs in 2011, compared with 16 percent in 2009. In addition, 85 percent of hospitals have said they plan to implement meaningful use and take advantage of the incentive payments by 2015. CMS will likely release proposed rules for Stage 3 of meaningful use in 2014 for implementation in 2016 and beyond.

To read article at original location: https://www.aamc.org/newsroom/reporter/april2012/279214/meaningful-use.html

Value-Based Purchasing Presents Challenges to Teaching Hospitals

Published in the January 2012 Association of American Medical Colleges Reporter

By Whitney L.J. Howell

Starting October 2012, hospitals will be paid under a new Centers for Medicare and Medicaid Services (CMS) program that ties a percentage of their Medicare reimbursement to performance on a set of quality metrics, including patient satisfaction. Called a value-based purchasing (VBP) program, it is one of three new performance-based payment programs under the Affordable Care Act. The other two payment programs focus on performance related to readmissions and hospital-acquired conditions.

Performing well under VBP will be both a challenge and a financial necessity for teaching hospitals. “It’s a fundamental responsibility of all physicians in all academic medical centers to deliver high-quality, cutting-edge care,” said David Longworth, M.D., chair of the Cleveland Clinic’s Medicine Institute. “Now, we’re being asked to find a way to increase the value of services while cutting costs. It will be challenging, but it’s imperative for our economic survival.”

The VBP program will combine a hospital’s score on a patient satisfaction survey, known as the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS), with the facility’s success on 12 process-of-care measures in areas such as heart failure, pneumonia, and health care-associated infections. Poor performance on these measures can mean a reduction in reimbursement—when providers and facilities are already fighting to retain their payments.

Teaching hospitals continue to have concerns over how the program is structured, specifically the current emphasis on the HCAHPS survey. While patient satisfaction is a critical component to quality of care, recent research has shown that a sicker patient population could lead to lower scores and ultimately affect how teaching hospitals will fare under the new program.

“Value-based purchasing will be a real challenge for academic medical centers because they have the most difficult patient population,” said Robert Berenson, M.D., an internist and health care policy expert with the Urban Institute, a nonpartisan commission that analyzes public policy issues. “There is a concern that these facilities will not look like they are doing as well as community hospitals because they often provide more complex care to patients who are already more likely to have a negative outcome.”

However, many teaching hospitals have been incorporating quality-improvement strategies to prepare for the new payment program.

The Cleveland Clinic is using a number of strategies to improve its HCAHPS scores; however, Longworth emphasized that true differences in quality performance start with medical education.

“We’re embedding value by introducing medical students and residents to quality measures and outcomes,” he said. “This way they understand from the beginning that it is our moral imperative as health care professionals to do what we can to improve care quality.”

In 2010, the Cleveland Clinic held a Patient Experience Summit, dedicated to discussing patient quality of care and best practices.

New York-Presbyterian Hospital has several strategies in place, according to Eliot Lazar, M.D., senior vice president and chief quality and patient safety officer. The goal, he said, is to ensure that hospital employees understand the overall importance of quality and patient safety.

“It’s extremely important that our staff understand how to provide the highest-quality care whether it’s based on value-based purchasing or the Joint Commission,” Lazar said. “We make a point of integrating value-based goals with recommendations from our own experiences and national patient safety standards to create a cohesive quality and cost-controlling curricula.”

Residents from the hospital’s affiliated medical schools—Weill Cornell Medical College and Columbia University College of Physicians and Surgeons—have formed Housestaff Quality Councils (HQCs) to give administrators feedback about issues or problems they see at the front lines of patient care. Representatives from all departments meet monthly to craft solutions to common issues that will be easy to implement. For example, the Weill Cornell HQC improved the hospital’s medication reconciliation program by recommending that the electronic health record (EHR) prompt residents to perform a medication reconciliation within six hours of an admission. The EHR also prohibits further orders if the reconciliation is not completed within 18 hours.

“These councils are an excellent way for us to hear from residents who are out there with the patients,” Lazar said. “There are many times when we seek advice from the councils.”

“With less than a year left to gear up for VBP, the AAMC is fully committed to helping its member institutions identify the best strategies that will help them meet the quality-improvement and cost-reduction requirements,” said Jennifer Faerberg, AAMC director of health care affairs.

“We are working with institutions that have taken steps to make VBP implementation easier,” she said. “We are developing a forum for institutions to share their best practices. We cannot change the institutional structure or the patient dynamics, but we can help members do the best they can with what they have.”

To view the article in its original location: https://www.aamc.org/newsroom/reporter/january2012/271170/value-basedpurchasing.html

Accountable Care: Let the Work Begin

Published in the Dec. 12, 2011, Billian’s HealthDATA/Porter Research Hub e-newsletter

By Whitney L.J. Howell

One of the hottest topics in the health sector today is accountable care. The premise seems simple: Providers and clinical settings of all types will closely collaborate and share responsibility for providing patient care. Implementation, however, can be challenging, according to many hospital leaders and industry experts.

The Centers for Medicare & Medicaid Services (CMS) released its final rule on accountable care organizations (ACOs) in October, detailing how its version of an ACO – the Medicare Shared Savings Plan – should be structured. If facilities choose to enroll in this program, they must offer services to at least 5,000 Medicare recipients for at least three years. Providers and clinical settings are also free to design and implement their own collaborative care model that uses a network of physicians and facilities to provide coordinated care.

Past attempts at managed care have failed, and there is still a chance the U.S. Supreme Court could declare ACOs unconstitutional. But that hasn’t stopped some in healthcare from working toward more team-based care. They are advocates of a new form of healthcare – one that ultimately focuses on the health of the patient rather than the bottom line. They are betting that the changes that come with accountable care, repealed or not, will help to usher in and get providers comfortable with this more team-based approach.

“The path forward to accountable care seems brighter and more achievable to many health systems, community providers and small practices,” said Justin Barnes, Vice President of Marketing, Industry, and Government Affairs at Greenway Medical Technologies Inc. “There is flexibility within creating a model for accountable care; and, with the final rule, many care providers are seeing that accountable care is the future of where healthcare is going.”

Barnes was also central to the formation of  the Accountable Care Community of Practice, a group of healthcare information technology providers committed to helping providers and facilities successfully design and implement either a formal ACO business model or less formal accountable care strategy.

Although this care model is getting significant attention, Barnes said, much still needs to shake out before it can be declared a success. In the meantime, many providers are putting the pieces that will support it – healthcare IT, shared-risk plans and provider networks – in place.

Mentors can Make the Difference

However, pivoting from a fee-for-service delivery model to one that prizes teamwork and increased quality at a lower cost isn’t necessarily intuitive. Many hospitals – large, small, urban and rural – need guidance, said Julie Sanderson-Austin, RN, a quality management professional with the American Medical Group Association (AMGA).

“The ACO model and even accountable care are very different animals,” she said. “It’s clear that this isn’t business-as-usual and that the change to healthcare is significant.”

To support facilities moving toward team-based care, the AMGA launched its learning collaboratives program last year. The goal, Sanderson-Austin said, is to help hospitals design ACO models that fit their specific needs by pairing facilities just embarking on accountable care conversations with mentor institutions that are further along in implementation.

Defining and Addressing Challenges

Hospitals just approaching accountable care voice some of the same concerns and encounter similar challenges, Sanderson-Austin said. For many, the biggest problem is integrating their data across care settings to offer patients a complete continuum of care. Having an electronic health record (EHR) connecting the hospital to its outpatient clinics is a good start, but it isn’t enough.

“It’s great to have an EHR that connects to ambulatory sites, but it has to be connected to your other sites, as well,” she said. “Otherwise, how are you going to get data from your nursing homes or home health agencies? If your patients either have to or elect to go to a nursing facility, you need a way to access their information for any possible future care needs.”

The initial capital investment needed to acquire good technology or build fluid health information exchanges can also present substantial problems, especially for smaller facilities, said Erik Johnson, Senior Vice President of consulting firm Avalere Health.

Although physicians are slated to play a vital role in any collaborative model, they can also be a significant sticking point for administrators looking to re-vamp how their facilities provide services. Even hospitals that began looking to a more team-based approach years ago have struggled to bring any changes to fruition.

“Improving engagement between physicians and hospitals continues to be an up-at-night problem for hospital executives,” Johnson said. “It’s difficult to get this kind of alignment.”

The Greenville Hospital System University Medical Center (GHSUMC) encountered this problem when it first considered its own type of ACO roughly a decade ago. According to Chief Medical Officer Angelo Sinopoli, M.D., convincing the doctors was an uphill battle.

“It took 10 years for physicians to embrace the model,” he said. “The concept is foreign because physicians train as individuals and are not accustomed to working in teams.”

However, administrators repeated the facility’s long-term goal and worked to educate the doctors on the benefits of working with other providers. Eventually, Sinopoli said, the physicians became champions of the hospital’s new care model.

Laying the Groundwork

Even though these challenges exist, hospitals can lay the groundwork for accountable care success, said Eric Bieber, M.D., President of the Accountable Care Organization at University Hospitals in Cleveland.

“Creating a collaborative care system that works well requires a high-functioning, multidisciplinary team to work across the organization,” Bieber said. “This team will be responsible for negotiating how the different groups within the hospital come together and divide risk.”

In January, University Hospitals launched its own accountable care model – a self-insurance plan that covers approximately 24,000 people. The facility is still in the process of identifying what works well and what doesn’t, but Bieber said institutions looking to follow in his hospital’s footsteps should bring together representatives from human resources and the legal department, as well as case managers, to discuss best strategies.

Industry management consultants at Kurt Salmon Associates also recommend hospital administrators focus on a few fundamental changes to position their facilities ahead of the curve.

Perhaps the biggest shift for hospitals, according to Kurt Salmon consultants Kate Lovrien and Luke Peterson, will be that pivot from concentrating on what the facility provides to honing in on what the community needs. With the ultimate goal of preventing inpatient admissions, the hospital is no longer the center of healthcare.

“There needs to be a dramatic change in organizational culture from the inside-out thinking of ‘my care, my time, my location’ to the outside-in thinking of ‘right care, right time, right location,’” Lovrien and Peterson wrote in a statement about ACO preparations, adding that this altered view constitutes a vision change for many facilities, and to do it well, administrators must secure buy-in from their board and staff members.

In addition, a facility’s business model must change. Under accountable care, success will no longer be measured in patient volume or the amount of services provided. Instead, efficiency and efficacy will be based on how well facilities control their costs while providing superior quality. Lovrien and Peterson seem to agree with Bieber – outlining how responsibilities will be divided and shared is a critical step. This move will give the hospital a clear organizational model, bolstering the ambulatory care system and streamlining the continuum of care across settings. The result, they said, will be improved quality and cost control.

Physicians must also turn from being the biggest hindrances to accountable care to being the most enthusiastic foot soldiers in the ramp up to the new care model, they said.  With their knowledge of the interplay between clinical activities, healthcare economics, and provider-patient engagement, doctors can strengthen the bonds across care settings.

Lastly, success will also come easier if hospitals tailor any EHR system to quality measures that are unique to the populations they serve.

Whatever strategies hospitals choose to employ, all facilities would be wise to start giving serious thought to what their accountable care model might look like, Bieber said. Waiting for Congress to announce a directive would be a waste of time.

“Regardless of the result of the elections in November 2012, there’s real support on both sides of the aisle for accountable care concepts,” he said. “It would behoove all organizations to begin to think about a system that focuses on maintaining wellness and managing chronic disease.”

To see the article at its original location: http://www.porterresearch.com/Resource_Center/Blog_News/Industry_News/2011/December/Accountable_Carex_Let_the_Work_Begin.html